May 14th, 2009 by DrRob in Better Health Network
No Comments »
I met a urologist from another city recently. Since it had been a much discussed issue recently, I asked him what he thought about PSA testing. His answer was immediate.
“I think PSA testing has been proven to save lives, and I have no doubt it should be done routinely.”
When I mentioned the recent recommendation that prostate cancer screening be stopped after a man reaches 70, his faced turned red. “That report is clearly an attempt by the liberal media to set the stage for rationing of healthcare. It was a flawed study and should not be taken as the final say on the matter.” He went on to recount cases of otherwise healthy 80 year-old men who developed high-grade prostate cancer, suffered, and died.
I chose not to debate him on the subject, but did point out that his view was that of one who sees the worst of the worst. I personally can recall less than ten patients who died of prostate cancer in the fifteen years I have practiced. My view is one that sees a non-diseased general public, and not worst-case scenarios. I also didn’t point out that even the American Cancer Society stopped pushing the test and states, and does not think as highly of the evidence as he does: “Using the PSA test to screen men for prostate cancer is controversial because it is not yet known for certain whether this test actually saves lives.” (1).
But I digress. What really struck me in the discussion was the way he pulled out the idea of rationing as the end-all hell for American healthcare. It is regularly used as a scare tactic for those who advocate a “free market approach” to healthcare. They point to the UK and Canada where people are denied cancer treatment or delayed repair of a ruptured disc resulting in permanent paralysis. Rationing healthcare seems a universal evil, and any step that is made toward controlling cost is felt by some to be a push of the agenda of the Obama administration toward universal health coverage and ultimately rationing.
So what exactly is so bad about rationing? The word itself refers to an individual being given a set amount of a limited resource, above which none will be available. In healthcare, the idea is that each American is given only a set amount of coverage for care and above that they are left to fend for themselves. Those who are either go over their limit or are felt to have a less legitimate claim on a scarce resource will be denied it. This is especially scary for those who are the high-utilizers (the uninsurable that I have discussed previously), as they will use up their ration cards much faster than others. I certainly understand this fear.
But are all limitations put on care really a step toward rationing? Are limits put on care a bad thing? The answer to that is simple: DUH! Of course not! Of course there need to be limits on care! Without control over what is paid for, the system will fall apart. Here’s why:
- Limited Resources – Not only are our resources limited, they need shrinking. The overall cost of our system is very high and has to be controlled somehow. Different interests are competing for resources, and by definition whoever doesn’t win, doesn’t get paid. This means that someone needs to prioritize what is a necessity and what is not.
- Lack of personal culpability by patients – with both privately and publicly funded insurance, the actual cost to the patient is defrayed. They are not harmed by unnecessary spending, so they don’t try to control it. Only uninsured patients are painfully aware of the cost of unnecessry tests.
- Lack of personal culpability by doctors – If I order an unnecessary test or expensive drug, I am not harmed by the waste. For example, it is common practice by emergency physicians in our area to get a chest x-ray on children with fever. Most of this is related to defensive medicine which is understandable in the ER, but clinically the test is often not warranted. Yet the emergency physicians are not really affected by this waste, and the hospital and radiologists are actually rewarded by it if the insurance company pays for it (which they do).
- Incentives for other parties – As I just said, hospitals and radiologists have incentives to have wasteful procedures done. The urologist I spoke to has a huge financial stake in the continuation of PSA testing, as it generates enormous business for him. Drug companies want us to order their more expensive drugs than the generic alternatives. This doesn’t mean any of them are wrong, but they sure as heck won’t fight waste if it harms them financially to do so.
When I was a physician starting out, the insurance companies would pay for pretty much any drug I prescribed. At that time there were very expensive branded anti-inflamatory drugs that were aggressively pushed by the drug companies. When the first drug formulary came around, the first thing that happened was that they forced me to use generic drugs of this type. Before, there was no reason not to prescribe a brand, I had samples, and they were a tiny bit more convenient. But when I changed there was really no negative effect on my patients.
One of our local hospitals just built a huge new cardiac center. Statistically, our area is a very high-consumer of coronary artery stents compared to the national average. Yet there are many cases in which an asymptomatic person will get a stent placed simply because they have abnormalities on their cardiac catheterization. Logically this may make sense, but the data do not suggest that these people are helped at all. Do you think that the hospital wants these procedures halted? Do you think the cardiologists do? Yet if they are truly unnecessary, shouldn’t they be stopped? Couldn’t the $200 million they spent on their state-of-the-art facility be used in better ways? Someone has to be looking at this and making sure the money spent is not wasted.
Without cost control a business will fail, and the same goes for our system. Yet any suggestion at the elimination of clinically questionable procedures is met with cries of rationing. Right now we are not at the point of rationing, and the act of trying to control cost by eliminating unnecessary procedures does not necessarily imply that the end goal is rationing. The end goal is to spend money on necessary procedures instead of waste. I sincerely doubt there is a left-wing conspiracy to push us to deny care where it is needed. I doubt that the American Cancer Society is in favor of rationing.
Let’s just spend our money wisely. It’s just common sense; not an evil plot.
*This blog post was originally published at Musings of a Distractible Mind*
May 14th, 2009 by GruntDoc in Better Health Network
No Comments »
So typical a colleague remarked on it.
*This blog post was originally published at GruntDoc*
May 14th, 2009 by Stacy Stryer, M.D. in Opinion
2 Comments »
School is almost out and your child will soon be on his way to sleep away camp. By the number of camp physicals I have been filling out recently, I can tell you that a lot of kids are sleeping away from home this summer. Most are so excited that they are counting the number of days and hours until they leave. And, believe it or not, their parents are excited, too. A whole week, or two, or three without being a maid or chauffeur. Only in my dreams!
Some kids, however, are a little less than enthusiastic. Summer camp can be a great experience and most kids love it – but only when they are ready. If your child really doesn’t want to go and has a hard time separating from you, he may not be ready yet. And, as much as you would love to get a break, you may want to wait until next summer. Remember that there is no law stating that your child must attend a sleep away camp before becoming an adult. There are plenty of kids who never go to camp and, guess what? They grow up to be wonderful, successful, adventurous adults!
However, before you throw away your much needed break this summer, there are some things you can do to make it more likely your less-than-willing child will want to go to camp and will end up loving it. Below are a few things you can do to ease him into thinking about camp and making him feel less homesick if, in the end, everyone decides to give it a try.
· Start by having him sleep over at a friend’s or relative’s house.
· Invite a friend over who has been to sleep away camp and have him tell your child all about it
· Look for a camp that doesn’t last too long and isn’t too far away from home.
· Try to find a friend or a sibling who wants to go with your child
· Go visit the camp (if possible) and show your child where he will eat, sleep, and do various activities
· Find a camp that has similar interests to your child’s
· Send your child to camp with a special shirt, stuffed animal, or something else from home
· Mail letters and packages early and often so your child knows you are thinking of him (you can even send one in advance so it is there the day your child arrives)
If and when he decides to go, chances are he will have a great time and want to go longer next year (so be careful of what you wish for!)
May 13th, 2009 by admin in Better Health Network
No Comments »
We are all trying to cut back at the grocery store, but do you always have to get fresh produce? Not necessarily. I am always all for getting lots of fruits and veggies in whatever form. But I often hear people tell me they don’t think canned is as good as fresh. Hopefully I can set the record straight.
Canned food is often less expensive than frozen or fresh. It is also very convenient. You won’t throw away moldy or freezer burned foods. They are much more shelf stable so you can stock your pantry and always have something healthy on hand. And if you have been reading the Diet Dish for long, you know that I LOVE canned beans!
Fresh is not always best
A study from UC Davis found that all cooked forms of fruits and veggies–whether they come from fresh, frozen, or canned– are nutritionally similar. In fact, many foods are actually more nutritious in canned form. For example, canned pumpkin is higher in Vitamin A than an equal amount of cooked fresh pumpkin because the canning process concentrates the food. Canned tomatoes are higher in lycopene because the heat from the canning process helps the body absorb the lycopene better. The same is true for carotenoids in carrots, spinach, and other leafy greens and lutein in corn.
Surprising ways to use canned food
I just made three recipes I found on mealtime.org which is the website for the Canned Food Alliance.
Green Sal
ad with Posole and Creamy Cilantro-Lime Dressing
This green salad is dressed with the most amazing creamy cilantro lime dressing. It is so good I wish you could taste it through the screen. What I love about this recipe is that you use only 1 T. of oil (instead of 1/2 or more cup per recipe) because you use pureed cannelini beans. This adds fiber and reduces calories and fat. Did I mention how yummy it is? Oh, and just in case you didn’t know (I didn’t), Posole is simply white corn.
Canned items in this recipe:
- Cannelini beans
- Mild green chilis
- Posole (also called hominy which is white corn)
- Slice ripe black olives
Caribbean Stir-Fri
ed Shrimp
I made this last night and my husband went back for seconds. Even Basil (almost 2 year old) ate it up! Uses frozen shrimp, canned pinepple, and tomatoes. It took me 15 minutes to make. I served it with instant brown rice. Tasty!
Canned items in this recipe:
- Pineapple chunks in juice
- Diced tomatoes
- Mild green chilis
Red Satin Cake w
ith Peaches and Raspberries
OK…ready for dessert now? You would never believe that this cake has pureed beets in it. I hate beets (sorry, but true). But I wanted to see how this would taste. Outstanding! You simply put the entire can of beets in the blender and mix it into a boxed mix of devil’s food cake and some eggs. No oil in cake mix because beets provide the moisture. Then you take canned peaches in juice and blend with cornstarch and boil to thicken for the filling. So easy!
Canned items in this recipe:
- No salt added sliced canned beets
- Sliced peaches in juice
For more recipes, check out the recipe section of www.mealtime.org
This post, Is Canned Food Good for You?, was originally published on
Healthine.com by Brian Westphal.
May 13th, 2009 by AlanDappenMD in Primary Care Wednesdays
No Comments »
“OK,” I can hear you say, “Enough about telemedicine. So what if you can prevent two-thirds of office visits by using the phones, or that it’s convenient for the patient and can start them on the road to recovery faster, or that it costs much less money than conducting an office visit, or that malpractice companies have accepted this delivery model.
I can see that you still side with the other non-believers in telemedicine, citing, “Telemedicine is no way to build relationship with patients. Problems abound with telemedicine: It’s too impersonal, patients could easily not be telling you the truth because you lose the “body language and facial expressions,” and it certainly can’t be useful for chronic illness. Maybe it’s good for the simple problems, but this has no place with complex or chronic medical care.”
I do, of course, have some rebuttals for you …
Let’s start with impersonal. In today’s world, we let our friends and family communicate with us constantly through phones and email, and I’ve yet to see how this has destroyed the intimacy of our relationships. So why do Americans anxiously wait up to four days for a doctor’s appointment to get their problem or question resolved and waste at least four hours of a day to get to the office simply to wait for an unpredictable time for a predictable 10-15 minutes of the doctor’s time when so many issues can be resolved remotely by phone? Furthermore, try convincing someone with a urinary tract infection (UTI) or that needs a prescription refill that their long wait, suffering, and run through the primary care funnel were “good for the relationship.” In fact, nothing is more personal that a doctor saying to their patients, “Here is my direct phone number, please call me anytime you need help.” Viewing telemedicine from this perspective determines that the “impersonal” concern is a ruse to protect doctor’s privacy at the expense of their patients.
What about the patient who is not truthful? Does a face-to-face visit make this less likely? In 30 years of work, several patients I know have not always been honest. Many of these people were attractively dressed, well educated and for awhile, fooled me badly. I saw them all face to face too. To this day, I have no idea what to look for when someone is trying to pull the wool over my eyes.
If people are going to hide the truth, they can do it in person just as well as over the phone. When a doctor becomes suspicious about a patient’s truthfulness through a pattern of calls and behaviors, then a scheduled office visit may help. However, forcing office visits based on a blanket rule of thumb of not trusting your patients means there is something fundamentally wrong with the doctor-patient relationship.
Lastly is the idea that chronic disease management isn’t appropriate through phones and email. Really? Let’s say you had diabetes, or hypertension, or high cholesterol, or cancer, or depression, just to name a few. With one of these conditions, you will be in contact with your health professional a lot more than you are now. Not only is your life more complicated, but the doctor wants you to consume 10% of your life waiting to see him in person because it’s good for him. Instead, many of these visits can be conducted easily anytime through phone calls and email.
Here are some examples:
#1. A phone call: “Mr. Doe this is Dr Dappen. I see a calendar reminder that you’re due for labs to check your cholesterol and to make sure the statin drug we put you on is not causing problems. I’ve faxed the order to the lab that is located close to you home, so stop by anytime in the next week and they’ll draw the blood. I should have the results in 24 hours after your visit to the lab, and we can review the report over the phone at that time and decide if we need to make any change.”
#2. An email from a patient: “Dr. Dappen, I’ve been worrying about my blood pressure readings. Over the past 3 weeks, they’ve been running consistently higher. Not sure why and until recently the home readings were doing great. Attached is the spread sheet of readings. Look forward to your input.”
In fact, examples abound of how chronic disease management conducted via phones and email is more efficient, reduces costs, and improves outcomes; I’d invite any Doubting Thomas to visit the American Telemedicine Association for further inquiry. An entire telemedicine industry is gearing up to manage chronic illnesses and most of the time it has nothing to do with patients visiting doctors’ offices.
When all is said and analyzed, the conclusion is really simple as to why the use of telemedicine is not more prevalent: no one wants to pay a doctor the market value for the time it takes to answer a phone and expedite an acute problem or manage a chronic health care problem. No money means no mission. This means no phones, no email. Don’t think about it. See you in the office. Why ruin 2400 years of tradition?
